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Choosing a Good Psychotherapist

Uploaded 5/4/2011, approx. 6 minute read

My name is Sam Vaknin. I am the author of Malignant Self-Love, Narcissism Revisited.

The dogmatic scores of psychotherapy, such as psychoanalysis, psychodynamic therapies and behaviorism, more or less failed to ameliorate, let alone cure or heal, personality disorders. Disillusioned, mass therapies today adhere to one or more of three modern methods, brief therapy, a common factors approach and eclectic techniques.

Conventionally, brief therapies, as their name implies, are short-term but effective treatments. They involve a few rigidly structured sessions directed by the therapist. The patient is expected to be active and responsive. Both parties sign a therapeutic contract or alliance in which they define the goals of a therapy and consequently, its themes.

As opposed to earlier treatment modalities, brief therapies actually encourage anxiety because they believe that it has a catalytic and cathartic effect on the patient.

Supporters of the common factors approach point out that all psychotherapies are more or less equally efficient or rather similarly inefficient in treating personality disorders.

As Garfield noted in 1957, the first step per force involves a voluntary action. The subject, the patient, seeks help because he or she experiences intolerable discomfort, egodystonic, dysphoria, dysfunction. The act, this act of approaching the therapist is the first and indispensable factor associated with all therapeutic encounters regardless of their origins or methodology.

Another common factor is the fact that all talk therapies revolve around disclosure and confidences. The patient confesses his or her problems, burdens, worries, anxieties, fears, wishes, intrusive thoughts, compulsions, difficulties, failures, delusions, and generally the patient invites the therapist into the recesses of his or her innermost mental landscape.

The therapist leverages this torrent of data and elaborates on it through a series of attentive comments and probing, thought-provoking queries and insights.

This pattern of give and take should in time yield the relationship between customer, client, or patient and healer based on mutual trust and respect.

To many patients, this may well be the first healthy relationship they experience and a model to build on in the future.

Good therapy empowers the client and enhances her ability to properly gorge reality, enhances her reality test. It amounts to a comprehensive rethink of one's self and one's life.

With perspective comes a stable sense of self-worth, well-being, and competence, known collectively as self-confidence or self-esteem.

In 1961, a scholar by the name of Frank made a list of important elements in all psychotherapists, regardless of their intellectual provenance and technique.

The first is that the therapist should be trustworthy, competent, and caring. Therapists should facilitate behavioral modification in the patient by fostering hope and stimulating emotional arousal, as Theodore Millon puts it.

In other words, the patient should be re-introduced to his repressed or stunted emotions and thereby undergo a corrective emotional experience.

The therapist should help the patient develop insight about herself, a new way of looking at herself and her world and of understanding who she is.

All therapies must weather the inevitable crisis and demoralization that accompany the process of confronting oneself and one's shortcomings.

The loss of self-esteem and devastating feelings of inadequacy, helplessness, hopelessness, alienation, and even despair, they are all an integral, productive, and important part of the sessions, if handled properly and competently.

Compare this to eclectic psychotherapy.

The early days of the emerging discipline of psychology were inevitably rigidly dogmatic. Clinicians belonged to well-demarcated schools and practiced in strict accordance with canons of writings by masters such as Freud or Jung or Adler or Skinner.

Psychology was lesser science than an ideology or even an art form.

Freud's work, for instance, though incredibly insightful, is closer to literature and cultural studies than to proper evidence-based medicine.

Not so nowadays.

Mental health practitioners today freely borrow tools and techniques from a myriad therapeutic systems. They refuse to be labeled and boxed in.

The only principle that guides modern therapies is what works, the effectiveness of treatment modalities, not their intellectual roots.

The therapy insists these eclectics should be tailored to the patient, not the other way around.

This sounds self-evident, but as Lazarus pointed out in a series of articles in the 1970s, it is nothing less than revolutionary.

The therapist today is free to match techniques from any number of schools to presenting problems without committing himself to the theoretical apparatus or baggage that is associated with them.

The therapist can use psychoanalysis or behavioral methods while rejecting Freud's ideas on Skinner's theory, for instance.

Lazarus proposed that the appraisal of the efficacy and applicability of a treatment modality should be based on six data. He called them basic IB, behavior, effect, sensation, imagery, cognition, interpersonal relationships, and biology.

What are the patient's dysfunctional behavior patterns? How is her sensorium sense data? In what ways does her imagery connect with her problems, presenting symptoms and signs? Does he or she suffer from cognitive deficits and distortions? What is the extent and quality of the patient's interpersonal relationships? Does the subject suffer from any medical, genetic, or neurological problems that may affect his or her conduct and functioning?

Once the answers to these questions are correlated, the therapist should judge which treatment options are likely to yield the fastest and most durable outcomes.

And this is based on empirical data.

As Butler and Halkin noted in a groundbreaking article in 1990, therapists no longer harbor delusions of omnipotence.

Whether a course of therapy succeeds or not depends on numerous factors such as the therapist and the patient's personalities and past histories and the interactions between the various techniques used.

So what's the use of theorizing in psychology? Why not simply revert to trial and error and see what works?

Butler, a staunch supporter and promoter of eclecticism, provides the answer.

He says that psychological theories of personality allow us to be more selective. They provide guidelines as to which treatment modalities we should consider in any given situation and for any given patient.

Without these intellectual edifices, we would be lost in a sea of everything goes.

In other words, psychological theories are organizing principles, kind of filters. They provide the practitioner with selection rules and criteria that he or she would do well to apply if they don't want to drown in a sea of ill- delineated treatment notions.

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Zagreb Clinicians Seminar Notes and Summary (PDF LINK in Description)

The seminar covers various models of personality disorders, particularly focusing on Cluster B disorders, emphasizing the differences between categorical, dimensional, and trait domains models. It discusses the core role of pathological narcissism in these disorders, exploring psychodynamic features, trauma, and dissociation as critical factors in their development. The presentation also highlights the impact of early childhood experiences, particularly the influence of parental figures, on identity formation and the emergence of dissociative states. Finally, it outlines clinical features and traits associated with Cluster B personality disorders, including emotional dysregulation, impulsivity, and the need for external validation.


When Suggestible Patient Pleases Therapist (Conference Presentation)

Cluster B personality disorders share common features that suggest they could be unified under a single diagnosis, with suggestibility being a significant clinical characteristic that complicates therapy. Patients often adapt their identities to align with the expectations of their therapists, leading to a manipulative dynamic that can distort diagnoses and treatment outcomes. This process is exacerbated by transference and countertransference, where patients project past relationships onto therapists, creating a cycle of internalized and externalized aggression. Effective therapy requires therapists to maintain strong boundaries and humility, ensuring that the therapeutic relationship remains focused on the patient's needs rather than the therapist's desires or expectations.


Personality Types: Which Are YOU?

Type theory in psychology categorizes individuals based on personality characteristics, with historical roots tracing back to ancient Greek humoral theory and later developments by figures like Freud and Jung. Freud's libidinal types theory classifies personalities into erotic, obsessional, and narcissistic types based on the distribution of libido, while Jung's typology focuses on attitudinal and functional types, emphasizing introversion, extroversion, and the dominant functions of the psyche. Additionally, personality classifications such as type A, B, D, and T highlight various traits, with type A being competitive and ambitious, type B being easygoing, type D being distressed, and type T being thrill-seeking. Despite the appeal of categorizing personalities, the rigor and substantiation of these theories remain limited, reflecting a desire for control and understanding in a complex world.


How To Recognize Collapsed/Covert Personality Disorders

The lecture discusses the need for simplification in the understanding of personality disorders, particularly within the Cluster B category, suggesting that they may all stem from a single underlying phenomenon related to narcissism and the confusion between internal and external objects. It proposes that individuals with these disorders can transition between different states—overt, collapsed, and covert—based on external stressors and their responses to reality. The speaker emphasizes that both narcissists and individuals with borderline traits experience feelings of inadequacy and self-doubt, leading to various maladaptive behaviors and coping mechanisms. Ultimately, the lecture argues for a unified approach to understanding these disorders, highlighting the dynamics of personality and the interplay of internal and external influences on mental health.


GREAT NEWS New Treatments, BPD Redefined ( Borderline Personality Disorder Literature Review)

Recent research has revealed significant advancements in the understanding and treatment of borderline personality disorder (BPD), challenging previous misconceptions about its diagnosis and management. Notably, a study demonstrated that individuals with BPD do not need to engage in self-harm or suicidal behavior to qualify for the diagnosis, emphasizing the importance of emotional dysregulation as a key criterion. Additionally, new treatment modalities, such as combined individual and group schema therapy, have shown promise in effectively reducing BPD symptoms, while early interventions focusing on clinical case management rather than psychotherapy may be more beneficial for young patients. Overall, these findings suggest a shift towards a more nuanced and hopeful approach to diagnosing and treating BPD, highlighting the need for greater awareness and understanding among clinicians.


MMPI-2 Psychological Test: Controversial, but Hard to Fake

The MMPI-2 test booklet has 567 items, but a rough assessment can be made based on the first 370 queries. The items are arranged in scales, and the responses are compared to answers provided by control subjects. The nature of the deviation determines the patient's traits and tendencies, but not their diagnosis. The test results place the subject in a group of patients who reacted similarly, and the validity scales indicate whether the patient responded truthfully and accurately or was trying to manipulate the test. The clinical scales measure various mental health issues, and the interpretation of the MMPI-2 is now fully computerized.


Borderline Woman: Partner Devaluation, Self-harm, Alcoholism

The lecture discusses the psychological mechanisms underlying borderline personality disorder, focusing on splitting, self-destructive behaviors, and substance abuse. Splitting is described as a primitive defense mechanism that leads individuals to oscillate between idealization and devaluation of others, often rooted in childhood experiences. Self-destructive behaviors manifest in various forms, including reckless actions and unhealthy relationships, driven by internalized self-hatred and a fear of abandonment. Substance abuse is explored as a coping mechanism that exacerbates these issues, allowing individuals to escape emotional pain while simultaneously leading to further self-harm and relational difficulties.


CPTSD or Personality Disorder? (Compilation)

The lecture discusses the complexities of personality disorders, particularly focusing on the distinctions and overlaps between complex post-traumatic stress disorder (CPTSD) and borderline personality disorder (BPD). It argues that many individuals who identify with CPTSD may actually exhibit traits of BPD, as both conditions share symptoms such as emotional dysregulation and difficulties in interpersonal relationships. The speaker emphasizes that personality disorders can manifest as reactions to trauma experienced later in life, challenging the traditional view that these disorders stem solely from early childhood experiences. Additionally, the lecture highlights the need for a more nuanced understanding of personality disorders, suggesting that they may be better classified as post-traumatic conditions rather than fixed personality traits.


Mental Health Dictionary - Letter C

The lecture discusses various mental health concepts starting with the letter C, including catalypsy, catatonia, and compulsions. Catalypsy is characterized by the rigid maintenance of body positions, while catatonia encompasses a range of motoric abnormalities and was previously linked to schizophrenia but is now viewed as an affective disorder. Compulsions involve involuntary, repetitive actions that provide relief from anxiety, common in obsessive-compulsive disorders. The lecture also touches on concrete thinking, confabulation, and culture-bound syndromes, highlighting their significance in mental health diagnostics.


From Symbiotic Magical Thinking to Separation Trauma (Zagreb Clinicians Seminar, Part 2 of 5)

Trauma is a significant factor in the development of personality disorders, particularly in the context of childhood experiences and attachment styles. Individuals with Cluster B personality disorders exhibit traits such as magical thinking, cold empathy, and insecure attachment styles, which stem from early adverse experiences. The dynamics of these disorders often involve a dissociation from reality, leading to a fragmented sense of self and reliance on external validation. Ultimately, the interplay between maternal influence and the child's perception of self and others shapes the development of these disorders, highlighting the critical role of early relationships in psychological health.

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